Book Review

Growing Old Gracefully

The Oldest Old

N Engl J Med 1994; 331:484-485August 18, 1994

Article

The Oldest Old
Edited by Richard M. Suzman, David P. Willis, and Kenneth G. Manton. 444 pp. New York, Oxford University Press, 1993. $65. ISBN: 0-19-505060-6

The distinguished and meticulous journal for which I write this review asks all contributors to declare any prejudicial interest. This I am happy to do. Approaching 86 years of age, I am a fully qualified member of the cohort (a favored term of the authors) here under greatly detailed scrutiny. Attention is on what are designated and sometimes denigrated as the oldest old, those 85 or older. I can be assumed to harbor any plausible bias that comes from membership in this community.

I am not, however, conscious of any serious such bias in saying that this is a well-edited, richly informative book. It consists of 19 essays, the contributions of 41 academically distinguished authors who are a rich assortment of Ph.D.'s, M.D.'s, and other duly licensed scholars. Covered are the demographic characteristics of the very old, the problems of methodology in the study of the very old, the resort to health and institutional care, the social situation of the very old, and more briefly, the emerging question of social and medical policy appropriate thereto.

The writing is plain, effective, and purposeful, and only occasionally does literary excess intervene. One essay does begin with this flourish: “The diagonal march of birth cohorts across the grid of age and time is at once the most mundane and the most profound process known to demography.” Tut-tut! Dr. Samuel H. Preston and editors.

These lapses, however, are rare. One of my few other complaints was with a sentence that said, “An alarming possibility is that the mortality assumptions used by the Bureau of the Census may be far too conservative, and that the oldest-old population may grow more rapidly than even the highest projections.” I first read this as regretting the improved survival chances of my age group. Further reading, to my relief, made it clear that this was not intended.

Rather, the evidence here offered on my age bracket is reasonably, if not completely, reassuring. We are a rapidly growing segment of the total population. Our life expectancy is increasing, though at 85 and more not exactly spacious. As a male, my prospects are, indeed, far inferior to those of a woman. For this reason and because women marry at an earlier age, there are, however, far more presumptively lonely widows than widowers among my contemporaries. Also men, having that much larger opportunity for selection, are more likely to remarry at an advanced age than are women.

Much, though by no means all, of the medical and health news is less inspiring. Along with my colleagues among the old and oldest, I am heading toward a melancholy assortment of disorders, of which cardiovascular disease, Alzheimer's disease, cancer, and arthritis are among the most prominent candidates for concern. The likelihood of these afflictions is measured with meticulous and occasionally repetitive attention in these pages, and there follows a detailed discussion of how those so afflicted are cared for, including the approximately one fourth requiring institutional care.

All of this is fairly depressing, but there is a better side: “57 percent of all the oldest old living in the community experience little or no difficulty in going about their everyday activities without any personal assistance.” This account goes on to conclude that over a two-year period of study, “many retain their robustness and a smaller number, who are initially nonrobust, are apparently able to recover their robustness.” Here personal interest, perhaps innocent, certainly does intrude: I greatly hope to retain my present robustness, a word, incidentally, I will now especially cherish.

The book tells in vivid detail of the effect of my expanding age bracket on the larger economic and social situation. We do little real work, contribute almost not at all to the aggregate of economic output. Instead, by being more numerous and living longer, we are a drain, one not foreseen, on the Social Security system. And by living longer and often in more frail condition, we have medical, hospital, institutional, and other social costs not incurred by those who die younger and more economically. Here surely is the case for the cigarette. One can only hope that the big tobacco companies are not listening.

The darkest side of these essays comes with the examination of the income position of the oldest old. To put it bluntly, most -- a shocking proportion -- are very poor. A survey of incomes shows, as indicated, that they have no earnings to speak of. Many of the widows lost their access to pensions when their husbands kicked off. What remains for most is Social Security at a very modest level and some accumulated assets, most often the house. In the mid-1980s the median income of married couples over 80 -- not 85 -- was a distinctly modest $13,190. Half, to remind, had less. The median income of the unmarried was a miserly $5,940. A rich country should surely do better by its old. It nurtures the thought that the great increase in numbers of the oldest old may not be adding all that much to the aggregate of human happiness.

A related point. There is a missing chapter on how we speak to the old, a matter I have previously addressed. Our scheduled physical and probable mental decline must be accepted. What is less necessary is that we be reminded of it every day. “Are you still walking?” “Still writing, I see.” “Are you still interested in politics?” “Still enjoying life?” “I see that you still read the medical journals.” This is the omnipresent still syndrome. Alas, that so many good scholars should have failed to identify and condemn it.

Still, this is an excellent, interesting, informative, and intellectually responsible book. I'm not sure that I've given a fully adequate impression of the statistical material incorporated and carefully assessed, which is detailed and comprehensive. It is only that the authors should have allowed themselves a little more scope for indignation.

John Kenneth Galbraith, Ph.D.
Harvard University, Cambridge, MA 02138

Citing Articles (1)

Citing Articles

1. 1

   Richard Horton. (1997) The omnipresent still syndrome. The Lancet 350:9085, 1156
   CrossRef